Duration of prone position sessions: a prospective cohort study

Abstract

Background: Prone position (PP) is highly recommended in moderate-to-severe ARDS. However, the optimal duration of PP sessions remains unclear. We searched to evaluate the time required to obtain the maximum physiological effect, and to search for parameters related to patient survival in PP. Methods and results: It was a prospective, monocentric, physiological study. We included in the study all pronepositioned patients in our ICU between June 2016 and January 2018. Pulmonary mechanics, data from volumetric capnography and arterial blood gas were recorded before prone positioning, 2 h after proning, before return to a supine position (SP) and 2 h after return to SP. Dynamic parameters were recorded before proning and every 30 min during the session until 24 h. 103 patients (ARDS 95%) were included performing 231 PP sessions with a mean length of 21.5 ± 5 h per session. They presented a significant increase in pH, static compliance and P a O 2 /F i O 2 with a significant decrease in P a CO 2 , P plat , phase 3 slope of the volumetric capnography, P et CO 2 , V D /V T-phy and ΔP. The beneficial physiological effects continued after 16 h of PP and at least up to 24 h in some patients. The evolution of the respiratory parameters during the first session and also during the pooled sessions did not find any predictor of response to PP, whether before, during or 2 h after the return in SP. Conclusions: PP sessions should be prolonged at least 24 h and be extended in the event that the P a O 2 /F i O 2 ratio at 24 h remains below 150, especially since no criteria can predict which patient will benefit or not from it. Trial registration The trial has been registered on 28 June 2016 in ClinicalTrials.gov (NCT 02816190) (https ://clini caltr ials. gov/ct2/show/NCT02 81619 0?term=propo cap&rank=1).

Prone positioning during venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis

“…Of 812 potentially relevant publications, 27 full text publications were reviewed. Twelve observational studies of 640 patients met our inclusion criteria [ 10 , 17 – 27 ] Of the 12 studies, 11 were retrospective and one was prospective in nature; three were multi-center studies and the remaining were single-center studies. There was an overlap between two of the included studies [ 20 , 21 ], eleven studies (625 patients) were included in the meta-analysis [ 10 , 17 – 19 , 21 – 27 ] (Additional file 1 : Fig.…”

“…Planned subgroup analyses included influence of study population (Coronavirus Disease 2019 (COVID-19) vs. Non-COVID-19), type of PP regimen, duration to PP initiation, ECMO duration and JBI score. Analyses of RRs for cumulative mortality and complication incidence were conducted with continuity correction to allow for the inclusion of studies with zero events [ 17 ]. Sensitivity analysis was conducted by excluding studies with JBI score < 8 in the primary meta-analysis.…”

Prone position in ARDS patients: why, when, how and for whom

“…Even though long prone position sessions are advocated, the optimal duration is not definitely determined. Multimodality monitoring including lung and chest wall mechanics [72], electrical impedance tomography [73] and biomarkers may help clinicians to better determine the time to move the patient back to supine and/or to resume the prone position.…”

Prognostic Factors to Predict ICU Mortality in Patients with ARDS Who Received Early and Prolonged Prone Positioning Therapy

“…[37] A recent prospective study performed 231 PP sessions with a mean length of 21.5 ± 5 h per session in patients with ARDS and recommended that the duration of PP therapy should be ≥24 h, depending on whether PaO2/FiO2 remains <150. [40] In the current study, PP therapy was significantly longer than 20 h (median: 66.1 h, IQR: 44.4-85.4), with no significant difference between the surviving and nonsurviving groups (69.3 vs. 61.1 h, p = 0.170). Therefore, the dose of PP therapy is less likely to be a confounder in ICU mortality in this cohort.…”